Redefining the Culture for Patient Safety.ppt

Improving patient safety is about changing the culture in health care from one of blame to one where we examine our systems from beginning to end to reduce the opportunities for mistakes.

1. Redefining the Culture for Patient Safety
communication
collaboration
education
building
THE FOUNDATIONS
for patient SAFETY

2. Redefining the Culture for
Patient Safety
A common misconception is that patient safety is
about reminding people to be more careful.
But patient safety isn’t about cautioning health care
staff to be more careful.
In fact, we are some of the most careful people on
earth.
Improving patient safety is about changing the
culture in health care from one of blame to one
where we examine our systems from beginning to
end to reduce the opportunities for mistakes.

3. Not Who caused the accident
but
What caused the accident?
“Medical errors most often result from a complex interplay
of multiple factors. Only rarely are they due to the
carelessness or misconduct of single individuals.”
Lucien L. Leape, M.D.

4. Redefining the Culture for
Patient Safety
•Three concepts to move toward changing
the culture for patient safety
Swiss Cheese Model
Blunt and Sharp End
Hindsight Bias

5. Concept 1 “Swiss Cheese Model”
Accidents result from multiple factors not a
single failure
Many defenses exist to deflect failures
But, multiple failures align so error occurs
System review can help identify how
failures get through the defenses

6. Swiss Cheese Model
Defenses
Opportunity
for failure
ACCIDENT
System
System
System
System

7. Key Learnings of
Swiss Cheese Model
•Systems that rely on error-free performance
are doomed to failure
•Humans make mistakes
•Continue to strive for perfection but realize
humans are not perfect

8. Concept 2 “Blunt End/Sharp End Model”
•Blunt End = Organization’s policies,
procedures, resource allocations and
systems that may contribute to an error
•Sharp End = Direct caregivers at source of
contact with patient

9. Blunt and Sharp End
Policies, procedures,
resource allocation
systems
Blunt End
Sharp End
Direct
caregiver
Monitored Process E
R
R
O
R
Results

10. Key Learnings of
Blunt/Sharp End
•The “blunt end” may be a barrier or an
enabler for caregivers depending on how
policies and resources are designed
•The “sharp end” is constantly creating ways
to safeguard patients and make workaround
solutions to barriers everyday

11. Concept 3 Hindsight Bias
•Prior to the accident/error, many
intervening factors are evident and must be
considered in taking action.
•Yet after the accident, it seems clear that a
different action should have been taken.
•So hindsight bias is the phenomena in
which how an accident/error occurred
seems obvious after it has occurred.

12. Hindsight Bias
Before the Incident After the Incident
A B
B
A
D
C
Multiple Factors
Seems So Easy

13. Key Learnings of
Hindsight Bias
•Hindsight narrows the focus on the cause of
the failure/incident/error without considering
the whole picture, including all of the
environmental, emotional, political and
system issues surrounding the event
•Hindsight bias limits a complete and
thorough investigation
•Hindsight bias creates a tendency to ignore
system issues and focus on individual action

14. Using Concepts and Learnings
•Foundation for leaders to understand how
errors occur
•Knowledge to assist leaders in creating the
right safety minded culture
•Resources to support individual
organization initiatives

15. Nonpunitive/ Blameless Culture
•An environment of trust is established
•Non-blaming, responsibility-based
approach to causation of incidents/errors is
created
•Policy for non-blame is developed
•Expectations for timely error and near-miss
reporting and investigations are set
•Reporting is the norm

16. Nonpunitive/ Blameless Culture
•People are “rewarded” for reporting adverse events and near-
misses
•Leadership is involved in significant investigations
•Learnings are based on system/process improvements
•Performance based accountability mechanisms are separate
processes
•Staff involved in incidents are openly supported by leaders
(caregiver guilt/grief)

17. Nonpunitive/ Blameless Culture
•Empower staff to correct safety hazards
•Leadership communicates with medical staff and
employees to illustrate nonpunitive approach
•Language changes may reflect a positive approach to
patient safety and reporting
•Activities of risk and legal counsel are aligned with
patient safety agenda while protecting the organization

18. References/Resources
•Redefining the Culture for Patient Safety
(www.mhhp.com)
•AHA Strategies for Leadership: Hospital
Executives and Their Role in Patient Safety
(800-242-2626 #166924)
•Strategies for Leadership: An
Organizational Approach to Patient Safety
(www.aha.org/medicationsafety)

19. References/Resources
•AHA Strategies for Leadership Video Series (800-
242-2626 #166921; #166922; #166923)
•Beyond Blame Video by Bridge Medical
(www.mederrors.com)
•Elements of a Culture of Safety. Pennsylvania
Patient Safety Collaborative (717-564-6606)
•AHA Quality Advisory: A Culture of Safety–
Disclosure of Unanticipated Outcome Information
(www.aha.org)

20. References/Resources
•Sample survey on culture from Allina
Hospitals and Clinics
(www.ismp.org/Tools/AllinaAssessment.html)
Sample survey on culture from CareGroup
(contact Dr. Weingart for permission
[email protected])
Check FHALink at www.fha.org